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Clinical Nutrition
journal homepage: http://www.elsevier.com/locate/clnu
Departments of Geriatric Medicine, Uppsala University Hospital and Public Health and Caring Sciences, Clinical Nutrition and Metabolism, Uppsala
University, Uppsala, Sweden
b
Clinical Nutrition Unit, Sahlgrenska University Hospital and University of Gothenburg, Gothenburg, Sweden
c
Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
d
t, Oldenburg, Germany
Department of Geriatric Medicine, Carl von Ossietzky Universita
e
Department of Gastroenterology, Clinic of Intestinal Diseases and Nutritional Support, Hopital Erasme, Free University of Brussels, Brussels, Belgium
f
General and Oncology Surgery Unit, Stanley Dudrick's Memorial Hospital, Skawina, Poland
g
Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy
h
Department of Nutrition and Dietetics and Department of Medicine, Monash University Central Clinical School, Prahran, Australia
i
Department of Gastroenterology, Hepatology, Endocrinology, and Nutrition, Klinikum Bremen Mitte, Bremen, Germany
j
Department of Gastroenterology and Clinical Nutrition, University Hospital and University of Nice Sophia-Antipolis, Nice, France
k
Department of Nutrition and Dietetics, Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands
l
Department of Nutrition, Sports and Health, Faculty of Health and Social Studies, HAN University of Applied Sciences, Nijmegen, The Netherlands
m
Department of General Intensive Care, Institute for Nutrition Research, Rabin Medical Center, Sackler School of Medicine, Tel Aviv University, Petah Tikva
49100, Israel
a r t i c l e i n f o
s u m m a r y
Article history:
Received 27 February 2015
Accepted 3 March 2015
Objective: To provide a consensus-based minimum set of criteria for the diagnosis of malnutrition to be
applied independent of clinical setting and aetiology, and to unify international terminology.
Method: The European Society of Clinical Nutrition and Metabolism (ESPEN) appointed a group of
clinical scientists to perform a modied Delphi process, encompassing e-mail communications, face-toface meetings, in group questionnaires and ballots, as well as a ballot for the ESPEN membership.
Result: First, ESPEN recommends that subjects at risk of malnutrition are identied by validated
screening tools, and should be assessed and treated accordingly. Risk of malnutrition should have its own
ICD Code. Second, a unanimous consensus was reached to advocate two options for the diagnosis of
malnutrition. Option one requires body mass index (BMI, kg/m2) <18.5 to dene malnutrition. Option
two requires the combined nding of unintentional weight loss (mandatory) and at least one of either
reduced BMI or a low fat free mass index (FFMI). Weight loss could be either >10% of habitual weight
indenite of time, or >5% over 3 months. Reduced BMI is <20 or <22 kg/m2 in subjects younger and older
than 70 years, respectively. Low FFMI is <15 and <17 kg/m2 in females and males, respectively. About 12%
of ESPEN members participated in a ballot; >75% agreed; i.e. indicated 7 on a 10-graded scale of
acceptance, to this denition.
Conclusion: In individuals identied by screening as at risk of malnutrition, the diagnosis of malnutrition
should be based on either a low BMI (<18.5 kg/m2), or on the combined nding of weight loss together
with either reduced BMI (age-specic) or a low FFMI using sex-specic cut-offs.
2015 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.
Keywords:
Malnutrition
Nutritional assessment
Body composition
Denition
Consensus
Delphi
1. Introduction
http://dx.doi.org/10.1016/j.clnu.2015.03.001
0261-5614/ 2015 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.
336
2. Methods
2.1. Design of the delphi process and selection of the expert group
ESPEN decided in late 2012 to launch the initiative. In January
2013 representatives of more than 40 member countries of ESPEN
outlined the initiative and acknowledged the process. An international expert group consisting of experienced clinical scientists was
gathered to perform a modied Delphi process. The consensus
group participants, i.e. the authors behind this report, were chosen
to represent the clinical elds of medicine, surgery, intensive care,
oncology and geriatrics.
It was agreed within the group to base the process on open email communications, face-to-face meetings and on open as well as
closed ballots within the group. The intention was to maintain the
communication at each step until consensus for each milestone
(see below) was reached among all participants before the next
step was taken. Furthermore, the group agreed to seek the opinions
of the ESPEN members before deciding on the statement. Finally, it
was decided to perform validation studies of the nal statement.
This paper reports the process and outcome of the Delphi process,
i.e. the consensus based malnutrition diagnostic criteria, while the
validation studies are on-going and will be presented separately.
3. Results
3.1. How are screening and the diagnostic procedures interrelated?
There was a strong consensus from e-mail communications, a
one-day face-to-face meeting, and an anonymous group ballot that
the diagnostic procedure has to be based on the outcome of a
screening evaluation. Nutritional screening is always mandatory in
all clinical and care settings, since it is unanimously recognized that
patients affected by acute and chronic diseases are at high risk of
developing nutritional impairment. Diagnostic measures are only
needed for those cases that score positive for nutritional risk by any
of the validated screening tools. This consensus group does not
recommend any specic of the validated tools, as long as the tool is
validated for the setting where it is applied. Screening should be
sensitive, whereas diagnosis is specic. Thus, fewer will be diagnosed as suffering from malnutrition than the number of subjects
that are identied as being at risk. It was acknowledged that
measurements that were performed during the screening process
could potentially be used also for the diagnostic decision.
Risk of malnutrition was suggested to be as a diagnosis with
its own ICD Code. The general acceptance of the prevailing
malnutrition screening tools relies on the fact that fullling the
criteria for risk of malnutrition imposes negative clinical outcomes,
including death. Therefore it is crucial to commence nutritional
therapy as early as possible. Such intervention generates costs.
Therefore, the diagnosis of being at risk of malnutrition needs to
be coded and reimbursed in the ICD and DRG systems.
3.2. Which individual criteria do best capture the state of
malnutrition?
Nutritional variables are traditionally categorized as measures of
anthropometry, including body composition, biochemical indicators and data related to eating capability. The latter include
history as well as recording of actual food intake, or information on
factors for potential limitations of food intake like anorexia,
dysphagia or chewing problems.
A one-day face-to-face meeting was organized to scrutinize
these potential diagnostic criteria. Functional measures of strength
or power were soon dismissed as part of the diagnosis since they
were consensually viewed as not nutrition specic enough. Thus,
the following variables, or group of variables, were discussed as
potential criteria.
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3.2.1. Anthropometry
BMI and leg and arm anthropometry, e.g. calf circumference,
arm muscle circumference and triceps skinfold, are clinically
available objective variables with a fairly wide-spread use.
3.2.2. Body composition
Fat free mass (FFM) and fat mass (FM) can objectively be
measured by technical devices like bioelectrical bio-impedance
analyses (BIA), dual energy x-ray absorptiometry (DXA),
computed tomography (CT), ultrasound or magnetic resonance
imaging (MRI).
3.2.3. Weight loss
This reects a dynamic process that requires a negative energy
balance; i.e. a reduced food intake or increased energy expenditure.
3.2.4. Anorexia
Loss of appetite is a common complication to disease, medication and ageing. It is one of the most important mechanisms behind
weight loss.
Fig. 1. Outcome of the questionnaire on the preference of the individual criteria. Group
members were asked to grade from 1 to 6; 1 total disagreement and 6 total
agreement, on the use of each criterion. Scores of 1e2 was aggregated to being against,
scores of 5e6 as being for (pro) and 3e4 as in between (middle).
338
3.5.2. BMI
WHO advocates BMI <18.5 kg/m2 as a general cut-off for underweight. This cut-off is justied at a public health population
level [15], whereas its relevance for clinical and care settings may
be questioned. As already mentioned the trend of increasing BMI in
all populations world-wide make this acknowledged BMI cut-off
value difcult to use for the purpose of dening malnutrition. Patients struck with highly catabolic diseases may in 3e6 months lose
substantially more than 10% of their weight and still have BMI
values well above normal ranges. Another issue to consider is that
epidemiological evidence indicates that older populations display
higher optimal BMI intervals (e.g. for survival) than younger people.
Partly due to the strong global acceptance of the WHO cut-off of
18.5 kg/m2 it was decided unanimously to accept the WHO recommended cut-off of as a criterion that in its own right will be
enough to diagnose malnutrition.
With this latter decision it was easy to come to consensus for a
complementary suggestion for relevant BMI cut-off values; namely
<20 kg/m2 for subjects <70 years of age, and <22 kg/m2 for subjects
70 years and older, remembering the fact that these BMI levels need
to be linked to weight loss as dened above. The choices of 20 and
22 kg/m2, respectively, were based on consensus in the group.
Ethnic and regional variability in BMI may need to be considered.
3.5.3. FFMI
Cut-offs for FFMI need to be linked to the decided cut-offs for
BMI on one hand, and to the fact that women have lower FFMI (and
higher FMI) than men on the other hand. Based on Swiss reference
material [16] it was decided to suggest FFMI <15 and <17 kg/m2 in
women and men, respectively. It has to be emphasized that reference values, like for BMI, should be relevant for the specic ethnic
and cultural context that is at hand.
The result of this process is summarized in the Fact box.
Fact box: Two alternative ways to diagnose malnutrition.
Before diagnosis of malnutrition is considered it is
mandatory to fulfil criteria for being at risk of malnutrition
by any validated risk screening tool.
Alternative 1:
BMI <18.5 kg/m2
Alternative 2:
Weight loss (unintentional) > 10% indefinite of time, or
>5% over the last 3 months combined with either
BMI <20 kg/m2 if <70 years of age, or <22 kg/m2 if 70
years of age or
FFMI <15 and 17 kg/m2 in women and men, respectively.
3.6. ESPEN membership ballot
For transparency, implementation and awareness purposes the
nal consensus group suggestion for the malnutrition diagnostic
339
poll among the consensus group. Malnutrition had a slight preponderance with 53% of the votes as compared to 47% in favor of
undernutrition. Due to this uncertain result the consensus group
doesn't advocate any specic term, but has chosen to use malnutrition for this paper.
Finally, a conceptual tree of prevailing nutritional disorders was
constructed (Fig. 3), acknowledging the complex interactions between the conditions. The structure of Fig. 3 was discussed as some
in the consensus group preferred a less hierarchical arrangement of
the conditions.
4. Discussion
Fig. 2. ESPEN membership ballot. Vote count on the question We want you to indicate
on a scale from 1 to 10 whether you agree strongly 10, or disagree strongly 1, with
this suggestion (see Fact box).
This ESPEN Consensus Statement provides a novel, comprehensive, yet simple, format for the diagnosis of malnutrition. The
statement acknowledges the well-accepted BMI cut-off of 18.5 kg/
m2 provided by WHO. In addition, it introduces an alternative and
partly new format based on the combination of unintentional
weight loss, and low BMI or low FFMI, where the latter drives the
necessity to use modern techniques for body composition measurements. Regarding BMI, there was unanimous consensus that, in
the presence of signicant weight loss, BMI levels higher than
18.5 kg/m2 may also reect sufciently altered nutritional state to
warrant the diagnosis of malnutrition. The proposed cutoff values
of 20 (<70 y) and 22 (70 y) kg/m2 was the result from consensus
within the group. Validation studies have been launched to possibly
conrm these indications.
Recent years have seen the development of several malnutrition
screening tools, for example NRS-2002, MNA-SF and MUST, which
should be used for everybody that comes in contact with health and
elderly care. The purpose is to identify the individuals that will
need further nutritional assessment and that will need nutritional
therapy, in order to prevent the further nutritional deterioration
into malnutrition. To be dened as at risk for malnutrition according to any of the validated screening tools should render its
own ICD Code. Many of the validated screening tools in clinical use
today also provide grading into manifest malnutrition as well,
which is somewhat beyond their primary purpose. Since NRS-2002,
MNA-SF and MUST use different criteria and cut-offs, and were
designed for different purposes and populations [17], the prevalence of malnutrition in a specic population will differ with the
screening tool used. Moreover, as indicated the appropriate evaluation of nutritional therapy effects is affected by when the therapy
is applied, i.e. in late or early phases of malnutrition, as well as by
variations in the diagnostic criteria [18]. These examples illustrate
how acknowledgment and development of clinical nutrition may
suffer from the lack of clear diagnostic criteria for malnutrition.
As indicated the purpose of this initiative was to provide a
general diagnosis that is relevant for all subjects in all clinical settings. Recent years have seen the advent of improved conceptualization and better understanding of different forms of nutritional
disorders and malnutrition (Fig. 3). Nevertheless, the denition is
meant to be valid for all individuals no matter if starvation, acute or
chronic disease or ageing is the dominant underlying cause of the
state of malnutrition. As with all general diagnoses (compare
anemia) they need to be elaborated into sub-diagnoses which
indicate their etiologies to facilitate the best treatment. Thus, this
ESPEN statement also provides a conceptual tree where pure starvation, disease-related malnutrition (cachexia) [10,11], and the
concepts of sarcopenia [11,12] and frailty [13] are related to, and at
least partly over-arched by the general term of malnutrition.
The concepts of cachexia and sarcopenia pinpoint the importance of variations in body composition, i.e. fat and muscle mass, as
predictors of clinical outcome. The two-compartment model for
body composition, i.e. FMI and FFMI, offers a more precise
340
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